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Dr. Mara Gordon, a family physician in Camden, N.J., answers reader health questions monthly. Send in your question to: thrive@npr.org.
Q: I am in perimenopause. I keep seeing posts all over social media talking up menopausal hormone therapy as cure-all. Should I be taking hormones? Should everyone?
A: I’m not surprised that you’ve been hearing the hype. There’s been an explosion of menopause content from influencers, direct-to-consumer telehealth companies marketing to women in midlife, and new books and podcasts on the topic.
This is great news for women. Menopause has historically been under-studied and stigmatized, so I love seeing more open conversations about this stage of life. And the pendulum has swung on hormone therapy; medical groups now recommend it again for many patients, after years of cautioning against it.
It’s about time that women have access to treatments for the very real symptoms that can accompany menopause rather than being told to “deal with” their hot flashes or sleep disruption.
But I’m also seeing a lot of less-than-scientific misinformation out there that over-promises on what menopausal hormone therapy can do. There are also lots of less-than-ethical influencers who are looking to make a quick buck on unproven supplements and vitamins.
As I navigate the new focus on menopause care alongside my patients, I’ve realized how critical it is to separate the hype from the reality.
Here’s what the science says about menopausal hormone therapy — and what we don’t yet know.
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What we mean when we say hormone therapy
Two types of hormones tend to decline in female bodies as we age: estrogen and progesterone.
When doctors prescribe menopausal hormone therapy it’s typically either estrogen alone or estrogen plus a progestogen, a term that includes the progesterone naturally found in the body and the synthetic hormones that mimic it.
These medications come in many different formulations, including transdermal patches, pills, and vaginal creams and rings.
You can get systemic hormone therapy — that’s hormones that are absorbed throughout the body — or local therapy, like a vaginal estrogen that only affects the vulva. These treatments have different risks and benefits, and you might need different combinations of them depending on your symptoms.
Some doctors use testosterone to treat sexual dysfunction in women, but doctors generally don’t use the term menopausal hormone therapy when they’re talking about testosterone.
Why the pendulum has swung on hormone therapy
When I was in medical school in the 2010s, I learned that hormone therapy could be dangerous.
The idea came from the Women’s Health Initiative that followed thousands of women in midlife who were taking hormones throughout the 1990s and early 2000s. Researchers actually stopped it early because it seemed to show that hormone therapy increased risk of heart disease, breast cancer, stroke, and pulmonary embolism.
After this news, prescriptions for hormone therapy went down dramatically. In 1999-2000, 22% of American women over 40 were receiving menopausal hormone therapy, one study estimated. By 2010, researchers estimated that had dropped to just around 5% of women in that age group.
But then, researchers began to re-analyze data from the Women’s Health Initiative. The growing consensus is that menopausal hormone therapy is much safer than we thought for women in their late 40s and 50s.
Once that news started to spread — and go viral online — patient demand began to spike.
What symptoms are the hormones good at treating?
The primary reason doctors recommend systemic hormone therapy is to treat what are called vasomotor symptoms of menopause, otherwise known as “hot flashes.”
Some researchers estimate that up to 80% of women in the menopausal transition have hot flashes — and they can really affect women’s quality of life. Some of my patients tell me that they disrupt their sleep, their ability to focus at work, and sometimes feel so distracting that they don’t want to leave the house.
Systemic hormone therapy can help prevent fractures for those at high risk of osteoporosis. It also helps keep bones strong as women age, although most organizations don’t recommend it to be used only for this purpose. I think of bone loss prevention as a positive side effect of hormone therapy when I prescribe it for hot flashes, but it’s not clear that the benefits outweigh the risks for every single patient.
Hormone therapy is also used to treat premature menopause if a woman has had her ovaries removed.
Dryness and irritation in the vulva — known as the genitourinary syndrome of menopause — also often get better with hormone therapy. These symptoms often improve with an estrogen treatment in the vagina, such as a cream or a ring; systemic hormone therapy can help too.
And should I take them for heart health and longevity benefits?
Hormone therapy can be life-changing for women experiencing hot flashes. But it’s not the fountain of youth, as many influencers seem to promise.
Most major medical organizations — including the U.S. Preventive Services Task Force, the American College of Obstetricians and Gynecologists, and the Menopause Society — do not recommend hormone therapy for longevity, heart health, or preventing chronic conditions, based on the data currently available. (It’s not recommended for youthful-looking skin and hair, another overly optimistic claim I’ve seen online!)
Still, there’s some genuine uncertainty about whether or not hormone therapy might help prevent heart disease.
“It’s really an unanswered question right now,” said Dr. Karen Adams, a professor of obstetrics and gynecology at Stanford, where she directs the Program in Menopause and Healthy Aging.
Adams says there is promising research that suggests that hormone therapy, when taken before age 60 or within ten years since menopause, might help prevent atherosclerosis, heart attacks, and strokes. But other studies show that hormone therapy — particularly when taken over age 60 — has no cardiovascular benefit at all or may even increase heart disease risk.
Essentially, researchers say that using hormone therapy right around the menopausal transition, usually in a woman’s early 50s, seems to be much safer than using it later in life.
The way that women take hormones seems to matter, too. Research generally shows that transdermal estrogen — delivered through a patch — is less likely to cause blood clots than oral estrogen.
So for patients in their late 40s and 50s with hot flashes or night sweats, Adams liberally prescribes hormone therapy unless patients have a clear medical reason not to. (More on that below!) But when it comes to heart health, she tends to focus on other prevention tools, like blood pressure management, cholesterol medications, nutrition, and exercise.
“I don’t say, ‘Here, take hormone therapy. It’s going to keep you from having a heart attack,'” Adams said. “We don’t have that data. And I don’t make that promise.”
Who should not take hormones
There are definitely reasons to proceed with caution when it comes to menopausal hormone therapy.
Anyone who has had breast cancer, blood clots, or a heart attack or stroke should have an in-depth conversation with their doctor about it, because hormone therapy can make those conditions worse or increase the risk of them recurring.
If I saw a patient with one of those conditions who was experiencing hot flashes, I’d probably recommend they try a nonhormonal treatment option first. Certain types of antidepressants can reduce hot flash frequency and severity. If the antidepressants aren’t effective, women have several other options, including a medication called fezolinetant, which was approved by the Food and Drug Administration in 2023.
To help prevent loss of bone density in a patient who can’t take hormones, I’d recommend that old standby: exercise. Weight-bearing exercise is one of the most effective tools we have to help prevent osteoporosis.
A family history of breast cancer doesn’t mean a patient can’t consider hormone therapy. But it’s important to proceed with caution. In that scenario, I’d first do a formal breast cancer risk assessment and think about genetic testing for high-risk mutations.
If the patient really wanted to use hormone therapy, I’d recommend what professional prescribing guidelines suggest: Take the minimum dose of hormone therapy that effectively treats your symptoms for the shortest possible duration.
Ultimately, it’s about understanding your own values and preferences.
“I lay out the risks and benefits,” said Dr. Jessica Platt, a family physician in Massachusetts who focuses on women’s health and menopause care. “Giving people knowledge and also giving them patient autonomy.”
The bottom line
Just because menopause hormone therapy is much safer than doctors believed in the 2000s doesn’t mean it’s a cure-all. Adams is concerned that some women might end up using a treatment that does more harm than good.
“When we just say this is the fountain of youth, people believe that. And women can be harmed by that,” Adams said.
In my own practice, I’ve come to realize there’s no one-size-fits-all answer.
Hormone therapy can really improve my patients’ quality of life. It’s gratifying when a patient comes to see me and says, “Thank you! My hot flashes are finally under control!”
But hormone therapy, unfortunately, does not fix every ailment the online influencers promise it will. It’s not right for everyone.
Ultimately, the decision to use hormone therapy should be a discussion between doctor and patient that takes into account the patient’s medical history, symptoms, and values.
Dr. Mara Gordon is a family physician in Camden, N.J. She writes the newsletter Your Doctor Friend.
